Provider Demographics
NPI:1184815730
Name:LIBBY, DEREK R (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:R
Last Name:LIBBY
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Gender:M
Credentials:DO
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Mailing Address - Street 1:97A EXCHANGE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5016
Mailing Address - Country:US
Mailing Address - Phone:207-773-3335
Mailing Address - Fax:207-774-4788
Practice Address - Street 1:97A EXCHANGE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5016
Practice Address - Country:US
Practice Address - Phone:207-773-3335
Practice Address - Fax:207-774-4788
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2022-09-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME1967204D00000X
MEDO19672083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
0006954Medicare PIN